Severe compensatory hyperhidrosis after thoracic sympathectomy

A man was evaluated at age 35 years for burning/shooting pain in his left chest and drenching sweats affecting the lower trunk and legs since bilateral T₂-T₆ sympathectomy at age 22 for palmar and axillary hyperhidrosis. Thermoregulatory sweat test showed anhidrosis above T_5/6 (sparing the left T₂ dermatome) with rapid and profuse sweating elsewhere (figure). Severe compensatory hyperhidrosis is a known complication of extensive sympathectomy. Limited sympathotomy (disruption of fibers between stellate and T2 ganglia) or sympathectomy (e.g., T4 ganglionectomy) might be preferred for medically refractory palmar hyperhidrosis, maximizing palmar dryness, minimizing compensatory hyperhidrosis, and rarely causing intercostal neuralgia or Horner syndrome.^1,2 Medical therapy for hyperhidrosis, whether primary or compensatory, may include topical agents, oral medications with anticholinergic properties, or botulinum toxin injections; all were unsuccessful or not tolerated in this patient.